AD-761 Patent License for Government Inventions

OMB NO. 0518-0003

Expiration Date XX/XX/XXXX

United States Department of Agriculture PATENT LICENSE APPLICATION FOR GOVERNMENT INVENTIONS			1. AGENCY PATENT CASE NO. (Optional)      
			2. U.S. PATENT NO.      
			3. DATE OF PATENT   
6. TITLE OF PATENT/PATENT APPLICATION     			4. U.S. PATENT APPLICATION SERIAL NO.    
7. SOURCE OF INFORMATION CONCERNING AVAILABILITY OF THIS INVENTION   			5. TYPE OF LICENSE Exclusive Nonexclusive
8. NAME AND ADDRESS OF APPLICANT      		9. NAME AND ADDRESS OF REPRESENTATIVE TO WHOM CORRESPONDENCE SHOULD BE ADDRESSED      
10. STATE OF INCORPORATION (if corporation) or CITIZENSHIP (if an individual)      		11. TELEPHONE, FAX, AND EMAIL      
12. NATURE AND DESCRIPTION OF APPLICANT’S BUSINESS – Identify products or services successfully commercialized.      
13. APPROXIMATE NUMBER OF EMPLOYEES      		14. IS APPLICANT A SMALL BUSINESS CONCERN? YES NO
15. FIELD(S) OF USE IN WHICH APPLICANT INTENDS TO PRACTICE INVENTION      
16. IS APPLICANT WILLING TO ACCEPT A LICENSE FOR LESS THAN ALL FIELDS OF USE AS INDICATED IN ITEM 15 ABOVE? YES NO
17. SPECIAL TERMS OR CONDITIONS OF LICENSE DESIRED      
18. APPLICANT’S BEST KNOWLEDGE OF EXTENT TO WHICH THE INVENTION IS BEING PRACTICED BY PRIVATE INDUSTRY AND/OR GOVERNMENT, OR IS OTHERWISE AVAILABLE COMMERCIALLY      
19. GEOGRAPHIC AREAS IN WHICH APPLICANT INTENDS TO MAKE, USE, AND/OR SELL THIS INVENTION      
20. DETAILED DESCRIPTION OF DEVELOPMENT AND/OR MARKETING FOR EACH FIELD OF USE TO WHICH RIGHTS ARE SOUGHT (PLEASE REVIEW INSTRUCTIONS)      
21. ADDITIONAL INFORMATION TO SUPPORT APPLICATION      
22. Application is made for a license to practice in the United States, the Government-owned invention identified herein, in accordance with 35 USC 208	SIGNATURE OF APPLICANT or AUTHORIZED REPRESENTATIVE			DATE

Agency Disclosure of Estimated Burden (Rev. 11/24)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0518-0003. The time required to complete this information collection is estimated to average 3 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Applicants with suggestions for reducing this burden may contact:

U.S. Department of Agriculture, Agricultural Research Service, Research, Education, Economics, Administrative Financial Management, Information Technology Services Division, 5601 Sunnyside Ave., Beltsville, MD 20705.

Return Completed Application to the Office of Technology Transfer

Via Email to:

[email protected]

or

Via Postal Mail to:

Business Licensing Officer

U.S. Department of Agriculture

Agricultural Research Service

5601 Sunnyside Avenue, Rm 2-2110

Beltsville, Maryland 20705-5131

Form AD-761
Last Revised 11/25/2024